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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022086-carayon-final-report-2019.pdf
January 01, 2019 - 9 design sessions in which the design
team consisting of 6 human factors experts and 2 clinicians discussed … - either during
bedside or tabletop rounds -- to ensure need for
interruption or re-initiation is discussed
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www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
January 01, 2024 - As discussed above, we have successfully contracted with RxHub, a consortium of the
largest PBMs, and
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psnet.ahrq.gov/node/46541/psn-pdf
January 31, 2018 - The 2017 ACGME common work hour standards:
promoting physician learning and professional
development in a safe, humane environment.
January 31, 2018
Burchiel KJ, Zetterman RK, Ludmerer KM, et al. The 2017 ACGME Common Work Hour Standards:
Promoting Physician Learning and Professional Development in a Safe, Humane …
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psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
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psnet.ahrq.gov/node/61085/psn-pdf
November 04, 2020 - National drug shortages worsen during COVID-19 crisis:
proposal for a comprehensive model to monitor and
address critical drug shortages.
November 4, 2020
Piatek OI, Ning JC-min, Touchette DR. National drug shortages worsen during COVID-19 crisis: proposal
for a comprehensive model to monitor and address critical …
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psnet.ahrq.gov/node/836997/psn-pdf
April 27, 2022 - The effect of a transitional pharmaceutical care program
on the occurrence of ADEs after discharge from hospital
in patients with polypharmacy.
April 27, 2022
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. The effect of a transitional pharmaceutical care program on
the occurrence of ADEs after discharge from hospi…
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psnet.ahrq.gov/node/38758/psn-pdf
July 08, 2009 - An international review of patient safety measures in
radiotherapy practice.
July 8, 2009
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy
practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
https://psnet.ahrq.gov/issue/international…
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psnet.ahrq.gov/node/35856/psn-pdf
June 16, 2011 - The Safety Attitudes Questionnaire: psychometric
properties, benchmarking data, and emerging research.
June 16, 2011
Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties,
benchmarking data, and emerging research. BMC Health Serv Res. 2006;6(1):44. doi:10.1186/1472…
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psnet.ahrq.gov/node/40020/psn-pdf
September 20, 2011 - Case 34-2010: a 65-year-old woman with an incorrect
operation on the left hand.
September 20, 2011
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a
65-year-old woman with an incorrect operation on the left hand. N Engl J Med. 2010;363(20):1950-7.
doi:10.1056/NEJMcp…
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psnet.ahrq.gov/node/45631/psn-pdf
July 02, 2017 - Implementation science: a neglected opportunity to
accelerate improvements in the safety and quality of
surgical care.
July 2, 2017
Hull L, Athanasiou T, Russ S. Implementation Science: A Neglected Opportunity to Accelerate
Improvements in the Safety and Quality of Surgical Care. Ann Surg. 2017;265(6):1104-1112.
…
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psnet.ahrq.gov/node/37856/psn-pdf
June 16, 2011 - Improving patient safety in intensive care units in
Michigan.
June 16, 2011
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in
Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09.002.
https://psnet.ahrq.gov/issue/improving-patient-safety-intensive-…
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psnet.ahrq.gov/node/73350/psn-pdf
June 02, 2021 - Learning during crisis: the impact of COVID-19 on
hospital-acquired pressure injury incidence.
June 2, 2021
Polancich S, Hall AG, Miltner RS, et al. Learning during crisis: the impact of COVID-19 on hospital-acquired
pressure injury incidence. J Healthc Qual. 2021;43(3):137-144. doi:10.1097/jhq.0000000000000301.
h…
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psnet.ahrq.gov/node/73244/psn-pdf
May 12, 2021 - Ethical considerations and patient safety concerns for
cancelling non-urgent surgeries during the COVID-19
pandemic: a review.
May 12, 2021
Brown NJ, Wilson B, Szabadi S, et al. Ethical considerations and patient safety concerns for cancelling
non-urgent surgeries during the COVID-19 pandemic: a review. Patient Sa…
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psnet.ahrq.gov/node/72509/psn-pdf
November 25, 2020 - Closing the loop on test results to reduce communication
failures: a rapid review of evidence, practice and patient
perspectives.
November 25, 2020
Wright B, Lennox A, Graber ML, et al. Closing the loop on test results to reduce communication failures: a
rapid review of evidence, practice and patient perspectives.…
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psnet.ahrq.gov/node/862126/psn-pdf
February 07, 2024 - Why is safety in intrapartum electronic fetal monitoring so
hard? A qualitative study combining human
factors/ergonomics and social science analysis.
February 7, 2024
Lamé G, Liberati EG, Canham A, et al. Why is safety in intrapartum electronic fetal monitoring so hard? A
qualitative study combining human factors/…
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digital.ahrq.gov/principal-investigator/hess-rachel
January 01, 2023 - Hess, Rachel
Functional Assessment Screening Patient Reported Information: FAST-PRI - Final Report
Citation
Hess, R. Functional Assessment Screening Patient Reported Information: FAST- PRI - Final Report. (Prepared by University of Pittsburgh under Grant No. R18 HS018932). Roc…
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psnet.ahrq.gov/node/37292/psn-pdf
May 24, 2015 - Guilty, afraid, and alone — struggling with medical error.
May 24, 2015
Delbanco T, Bell SK. Guilty, afraid, and alone--struggling with medical error. N Engl J Med.
2007;357(17):1682-3.
https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error
Disclosure of medical errors remains an important a…
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psnet.ahrq.gov/node/39249/psn-pdf
September 30, 2015 - Patient participation: current knowledge and applicability
to patient safety.
September 30, 2015
Longtin Y, Sax H, Leape L, et al. Patient participation: current knowledge and applicability to patient safety.
Mayo Clin Proc. 2010;85(1):53-62. doi:10.4065/mcp.2009.0248.
https://psnet.ahrq.gov/issue/patient-particip…
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psnet.ahrq.gov/node/47573/psn-pdf
December 19, 2018 - Can communication-and-resolution programs achieve
their potential? Five key questions.
December 19, 2018
Gallagher TH, Mello MM, Sage WM, et al. Can Communication-And-Resolution Programs Achieve Their
Potential? Five Key Questions. Health Aff (Millwood). 2018;37(11):1845-1852.
doi:10.1377/hlthaff.2018.0727.
https…
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www.ahrq.gov/evidencenow/tools/registries-pros-cons.html
November 01, 2018 - Advantages and Disadvantages of Registries: Population Health
Resource: Advantages and Disadvantages of Registries (PDF, 173 KB, 1 page)
Registries can complement paper records or electronic health records (EHRs), which frequently do not have the functions needed for population management. Aligning with Ke…